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By Emily Ashurst Lung cancer Biggest risk factor: Smoking Asbestos exposure (mesothelioma) Most common metastasis site: Bone and Brain Different types - Small cell lung cancer (15-20%) - Non-small cell lung cancer (80-85%) - Adenocarcinoma - Squamous cell carcinoma - Large cell lung cancerLung cancer: Symptoms/History • Typically, over 40 years and smoker • Hemoptysis • Persistent or worsening cough >3weeks • Breathlessness • Persistent or recurrent chest infections • Chest pain, pleuritic • Fatigue • Weight loss • Appetite loss • Supraclavicular or cervical lymphadenopathy • Hoarse voice – tumour pressing on the laryngeal nerve • Bone/limb pain – Bone mets or HOA • Asbestos exposure – MesotheliomaLung cancer: Examination signs • Clubbing • Dull percussion over site of lesion • Enlarged supraclavicular/cervical lymph nodes • Pleural effusion – Stony dullness on percussion • Low O2 sats Horner’s syndrome (Pancoast tumour / Apical lung tumour) Causes unilateral disruption of sympathetic nerves to the face • Miosis (Pupil constriction) • Ptosis (Eyelid drooping) • Anhidrosis of the face (lack of sweating) Superior vena cava obstruction (oncological emergency) • Distended neck veins • Facial swelling/oedema Lung cancer: Small cell • Aggressive and grows and spreads faster than other lung cancers • Typically found in older patients who are smokers • Cancer of neuroendocrine cells in the lungs • Associated with ‘Paraneoplastic syndromes’ • Poorer prognosis - 2/3s have metastasis at presentation • Tend to be more chemotherapy responsive • Surgery only in T1N0, T2N0 disease Lung cancer: SCLC - Paraneoplastic syndromes SIADH (syndrome of inappropriate antidiuretic hormone Lambert-Eaton syndrome secretion) • Auto-antibodies which block release of Acetyl choline in neuromuscular junction • Causes low blood sodium (hyponatremia) and high urinary sodium • Proximal muscle weakness – difficulty climbing stairs, • ADH causes water reabsorption through aquaporins standing from a chair • SIADH is confirmed with a raised urinary sodium >30 • Nausea, Vomiting, Confusion, Seizures Cushing’s syndrome • Ectopic secretion of ACTH (Adrenocorticotropic hormone) – Hypertrophic osteoarthropathy (HOA) regulates cortisol • Hypertension, weight gain • New bone formation in periosteum of forearms and lower legs • Causes bone and joint pain and marked clubbing Adenocarcinoma • Most common form of lung cancer Lung cancer: • Originate in glandular cells which secrete mucous • Peripheral on imaging as tend to develop in small airways NSCLC types • Associated with smoking but also the most common form seen in non-smokers Squamous cell lung cancer • 2 most common type • Central as they occur in the squamous cells lining the airways • Form cavitating lesions • Hypercalcemia caused by tumour secretion of PTH Large cell - Can be anywhere in the lung - Grow and spread quickly - A subtype called large cell neuroendocrine carcinoma acts similarly to SCLC Lung cancer: Investigations Refer people using a suspected cancer pathway referral (2 weeks) for lung cancer if they: • Have chest X-ray findings that suggest lung cancer, or • Are aged 40 years and over with unexplained haemoptysis. Bloods – FBC, UE, LFT, Bone profile, Calcium Chest X-ray - Focal lesion - Pleural effusion - Widened mediastinum (enlarged lymph nodes)Lung cancer: Investigations CT scan (with contrast unless renally impaired) - Nodules <3cm, Mass >3cm - Spiculated appearance more likely malignant (jagged) - Nodules larger than 1cm more worrisome PET CT “Ensure that all people with lung cancer who could potentially have treatment with curative intent are offered PET-CT before treatment” – NICE - Uses radioactive glucose (fluorodeoxyglucose) - Cancer cells appear brighter due to inc uptake - Looks for spread of cancerLung cancer: Investigations Bronchoscopy + biopsy - A tube passed down the throat to the lungs - Takes a sample of the suspicious lung nodule - Analysed to see if and what type of cancer it is - If cancer is peripheral CT guided biopsy through the chest wall - Lymph node biopsy TNM Staging Tumour (0-4) T0 – No tumour T(1-4) Different sizes / Multiple in same lung lobe / In certain parts of the lung (near bronchus, visceral pleura etc.) Node (0-3) N0 – No node N – 1) Nodes within the lung or hilum / 2) Nodes in chest on same side as cancer / 3) Nodes on opposite side of chest, or above collar bone Metastasis (0-1 a-c M0 – No Mets M1 – a) Mets present in the other lung / b) A single met outside the chest / c) Mets are in multiple organsLung cancer: Management Treatment depends on cancer type, stage and performance status of patient Smoking cessation Surgery (NSCLC or SCLC that is small and hasn’t spread) - Wedge – Removes the cancer and some healthy tissue - Lobectomy- Remove entire lobe of lung the cancer is in - Pneumonectomy – Removes entire lung - Removal of lymph nodes Radiotherapy - Radiotherapy may be used to shrink larger tumours before surgery, or used after surgery (adjuvant) - Radiotherapy is sometimes combined with Chemotherapy, if surgery is not an option - Radiotherapy may be used to relieve symptoms even if the cancer is not treatable (palliative)Mesothelioma - Cancer of the pleura (mesothelium), asbestos exposure in 85-95% of mesothelioma cases - Asbestos exposure many years prior (20-60) - Industrial compensation - Shipyard workers, construction workers and boiler engineers - Similar symptoms to lung cancer – including clubbing - Can cause pleural effusions and pneumothoraxes - Pleural thickening on chest X-Ray - Poor prognosis unless found early, median survival 12 monthsPleural effusion: what is it? Fluid within the pleural space The space between the visceral and parietal pleuraPleural effusion: Symptoms • SOB • Pleuritic chest pain • Non-productive cough • Symptoms may be worse when lying flat • AsymptomaticPleural effusion: Signs • Stony dullness on percussion • Reduced breath sounds • Decreased tactile fremitus • Reduced chest expansion • Tracheal deviation – away from affected side • Low oxygen sats Pleural effusion: Transudative vs Exudative Transudative – Low protein, watery When fluid leaks into the pleural space from the blood vessels because there is increased hydrostatic pressure (fluid overload) or decreased oncotic pressure (low protein levels in the blood) Causes - Congestive heart failure - Liver cirrhosis - Nephrotic syndrome - Hypoalbuminemia - Meigs’ syndrome (benign ovarian tumours) Pleural effusion: Transudative vs Exudative Exudative – Protein rich Inflammation of the pulmonary vessels causes fluid to leak into the pleural space, or lymphatic drainage is poor Causes - Malignancy - Infection (pneumonia, TB) - SLE - RA - Pancreatitis - Sarcoidosis - Churg Strauss disease (eosinophilic granulomatosis with polyangiitis) Pleural effusion: CXR - White out appearance - Meniscus sign - Blunted costophrenic angles - Tracheal deviation Pneumonia - Bottom of lungs if patient sat upPleural effusion: Investigations Thoracentesis Ultrasound guided procedure where a needle is inserted above the rib into the pleural space to take a sample of the fluid. The fluid is analysed for pH, protein, LDH, cytology and microbiology - Transudative fluidis clear - Exudative fluid is cloudy Contrast CT Look for underlying pathology if exudative If the pleural fluid protein is less than 25g/L the fluid is a transudate If the pleural fluid protein is greater than 35g/L the fluid is an exudate If the pleural fluid protein level is 25-30g/L : Pleural effusion Classification: Lights criteria Pleural effusion: Management Remove fluid from pleural space via thoracentesis Needle is inserted in the mid scapula line, one intercostal space below the top of the effusion, and along the upper border of a rib to avoid damaging the neurovascular bundle Treatthe cause - Diuretics if caused by congestive heart failure - Chemo/radiotherapy if malignant cause - Antibiotics if infection If recurrentpleural effusions - Pleurodesis (sticking lung to chest wall to prevent fluid accumulation) - Indwelling pleural catheter Thanks for listening Please give feedback to be sent the slides